There are two momentous changes to CMS Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) reference guide, which will modify CMS‘s guidelines on amended reviews and zero dollar Medicare Set-Asides.
Per an email from CMS of January 21, 2025, effective July 17, 2025, CMS will no longer accept zero dollar MSA allocations for review. This change has been reflected in the January 17, 2025 WCMSA Reference Guide Version 4.2. As you may recall, submitting an MSA to CMS is never required, but the parties must always protect Medicare‘s interest. A CMS approval letter has always been a good vehicle for showing proof the protection of Medicare‘s interest in a settlement. While CMS will no longer accept or review zero dollar MSAs, we must provide documentation to support a zero dollar MSA. Items that will support a zero dollar MSA, which should be included as exhibits to any settlement, could include medical records from the claimant’s treating physician which state that the claimant will no longer require any treatment or medications related to the workers compensation incident, no treatment or indemnity has ever been paid other than investigational payments, a Notice of Denial of the claim or future medicals filed with the state, and/or Merit hearing Order on denial of compensability.
Also upcoming, effective April 7, 2025, amended review requests will be allowed at any time after a CMS approval letter has been issued. Currently, and historically, we have had to wait at least one year post CMS approval to request an amended review. The requirements will still remain that the case has not yet settled, and that the projected MSA has changed enough to result in 10% or $10,000 change (whichever is greater) than the CMS approved amount. This change has not been included in the January 17, 2025 WCMSA Reference Guide Version 4.2, but will be forthcoming.
Reference Guide link below.
https://www.cms.gov/files/document/wcmsa-reference-guide-version-42.pdf
CMS Update- Zero Dollar Allocations
